Naziv tijela kojemu se zahtjev podnosi OBRAZAC 9a

FORM 9a
Name of the authority to which the application is submitted
PRIJAMNI PE»AT
STAMP OF RECEIPT

ZAHTJEV ZA IZDAVANJE DOZVOLE ZA BORAVAK I RAD

APPLICATION FOR ISSUANCE OF STAY AND WORK PERMIT

Prvo izdavanje Produæenje

First issuance Extension

1. Prezime:
Surname:
2. Bivπe, odnosno roeno prezime:
Former or maiden surname:
3. Ime:
Given name(s):
4. Spol: Muπko Æensko OIB*
Sex: Male Female *upisuje se ukoliko je dodijeljen / to be entered if issued
5. Ime roditelja: Otac:
Given names of parents: Father:
Majka:
Mother:
6. Datum, mjesto i dræava roenja:
Date, place and state of birth:

7. Dræavljanstvo:
Nationality:
8. Adresa u Republici Hrvatskoj:
Address in the Republic of Croatia:
9. BraËno stanje:
Marital status:
neoæenjen / neudana izvanbraËna zajednica oæenjen / udana udovac / udovica rastavljen(a)
single common law marriage married widow(er) divorced
10. Podaci o djeci:
Details on children:
1. Ime, prezime:
Name, surname:
Datum, mjesto, dræava roenja i dræavljanstvo:
Date, place, state of birth and nationality:
2. Ime, prezime:
Name, surname:
Datum, mjesto, dræava roenja i dræavljanstvo:
Date, place, state of birth and nationality:
3. Ime, prezime:
Name, surname:
Datum, mjesto, dræava roenja i dræavljanstvo:
Date, place, state of birth and nationality:
4. Ime, prezime:
Name, surname:
Datum, mjesto, dræava roenja i dræavljanstvo:
Date, place, state of birth and nationality:
Naziv i mjesto πkole:
Name and place of school:
11. Adresa u inozemstvu:
Address in a foreign country:
12. Putna isprava podnositelja zahtjeva:
Travel document of the applicant:
Tijelo koje je izdalo putnu ispravu:
The authority that has issued the travel document:
Mjesto i datum izdavanja:
Place and date of issuance:
Broj: Isprava vrijedi do:
Number: Document valid until:
13. Ulazak u Republiku Hrvatsku:
Entry into the Republic of Croatia:
a) obveza posjedovanja vize: Da Ne
obligation to possess a visa: Yes No
b) viza broj:
visa number:
Vrijedi do: Tijelo koje je vizu izdalo:
Valid until: Issued by the authority
14. Podaci o poslodavcu:
Information about the employer:
1. Naziv poslodavca
Name of the employer
2. Sjediπte i adresa
Seat and address of the employer
3. Registarski broj u Hrvatskom zavodu za zdravstveno osiguranje
Registration number in the Croatian Health Insurance Institute
4. ©ifra djelatnosti OIB
Business activity code
5. Razdoblje za koje se zahtijeva dozvola od do
Period for which the permit is requested from to
6. Naziv radnog mjesta
Name of the job position
7. Godiπnja kvota DA NE
Yearly quota YES NO
8. Sezonsko zapoπljavanje DA NE
Seasonal employment YES NO
9. Dnevna migracija DA NE
Daily migration YES NO
15. Obrtnik u RH: DA NE
Craftsman in RC: YES NO
1. Naziv obrta
Name of craft
2. Sjediπte i adresa
Headquarters and address of the employer
3. Registarski broj u Hrvatskom zavodu za zdravstveno osiguranje
Registration number in the Croatian Health Insurance Institute
4. ©ifra djelatnosti
Code of activity
5. Razdoblje za koje se zahtijeva dozvola od do
Period for which the permit is requested from to
16. Pruæatelj usluge u ime inozemnog poslodavca DA NE
Provider of services on behalf of a foreign employer YES NO
1. Naziv tvrtke u RH
Name of company in RC
2. Sjediπte i adresa
Headquarters and address
3. Registarski broj u Hrvatskom zavodu za zdravstveno osiguranje
Registration number in the Croatian Health Insurance Institute
4. ©ifra djelatnosti OIB
Code of activity
5. Naziv inozemnog poslodavca, sjediπte i adresa
Name of foreign employer, headquarters and address

6. Razdoblje za koje se zahtijeva dozvola od do

Period for which the permit is requested from to
 7. StruËna sprema
Professional qualifications
8. Zanimanje
Occupation
9. Vrsta usluge
Type of service
17. Podatak o zdravstvenom osiguranju:
Information about health insurance:
18. Zakonske obveze uzdræavanja druge osobe:
Legal obligations for supporting other person(s):
19. Stupanj naobrazbe i zanimanje:
Level of education and occupation:
20. Predvieno trajanje boravka: od: do:
Anticipated period of stay: From: to:
21. Sluæenje vojnog roka:
Military service:
22. Zavrπna izjava:
Final statement:
a) Ovim potvrujem da su svi podaci navedeni u toËkama 1. - 21. potpuni, te da odgovaraju istini i podacima
u priloæenim dokumentima. Potvrde koje su na drugom jeziku priloæene su u hrvatskom prijevodu.
Hereby I confirm that all information given under Items 1. - 22. are complete, that they are true and correspond
to the data contained in the documents attached. Certificates in another language are attached in the Croatian
translation.
b) Ovim se obvezujem da Êu svaku promjenu osobnih podataka prije ulaska u Republiku Hrvatsku, putem
diplomatskih misija, odnosno konzularnih ureda Republike Hrvatske, dostaviti hrvatskim nadleænim tijelima.
Hereby I undertake, that I will communicate any change of my personal data to the Croatian competent
authorities through diplomatic missions or consular offices of the Republic of Croatia before entering the
Republic of Croatia.
c) Primam na znanje da su moji osobni podaci u svrhu sastavljanja zapisnika i arhiviranja informatiËki obraeni.
I take note that my personal data are computer processed for the purpose of drawing up the minutes and of filing.
d) Pristajem da se svi moji osobni podaci koji se navode na ovom obrascu mogu proslijediti na provjeru
nadleænim tijelima Republike Hrvatske u svrhu odluËivanja o ovome zahtjevu.
I hereby agree that all my personal data stated in this form may be submitted to the competent authorities
of the Republic of Croatia for the purpose of verification when deciding on this application.
e) Primam na znanje da moj zahtjev zbog nepotpunih i netoËnih podataka, kao i zbog neispunjavanja
toËke 22. b, 22. c i 22. d moæe biti odbijen.
I take note that my application may be refused on account of incomplete and inaccurate data as well as
noncompliance with the Subitems 23. b, 23. c and 23. d.

U , dana
In Date:

Potpis podnositelja zahtjeva:

Signature of the applicant:

fotografija
35 x 45 mm
Photo
Potpis sluæbene osobe:
Signature of the official person:

Popunjava sluæbena osoba kojoj je zahtjev podnesen:

To be filled out by the official person to whom the application was submitted:
Ishod postupka:
Result of the procedure:
Broj rjeπenja:
Number of decision:
Datum izdavanja odobrenja:
Date when the approval was issued:
Vrijedi od: do:
Valid from: until:

Potpis sluæbene osobe:

Signature of the official person:

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